MEDICARE: SALLY MILLER DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5101009568	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	SM009568	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1588663041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY MILLER DO

Provider Business Mailing Address
First Line	:	PO BOX 3318
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49501-3318
Country	:	US
Telephone Number	:	800-968-6866
Fax Number	:	616-532-7230

Provider Business Practice Location Address
First Line	:	906 BUSINESS PARK DR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-8683
Country	:	US
Telephone Number	:	800-968-6866
Fax Number	:	616-532-7230

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	02/21/2008

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Directions to “ SALLY MILLER DO” Practice Location

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